1
|
Skolarus TA, Hawley ST, Forman J, Sales AE, Sparks JB, Metreger T, Burns J, Caram MV, Radhakrishnan A, Dossett LA, Makarov DV, Leppert JT, Shelton JB, Stensland KD, Dunsmore J, Maclennan S, Saini S, Hollenbeck BK, Shahinian V, Wittmann DA, Deolankar V, Sriram S. Unpacking overuse of androgen deprivation therapy for prostate cancer to inform de-implementation strategies. Implement Sci Commun 2024; 5:37. [PMID: 38594740 PMCID: PMC11005280 DOI: 10.1186/s43058-024-00576-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/04/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Many men with prostate cancer will be exposed to androgen deprivation therapy (ADT). While evidence-based ADT use is common, ADT is also used in cases with no or limited evidence resulting in more harm than benefit, i.e., overuse. Since there are risks of ADT (e.g., diabetes, osteoporosis), it is important to understand the behaviors facilitating overuse to inform de-implementation strategies. For these reasons, we conducted a theory-informed survey study, including a discrete choice experiment (DCE), to better understand ADT overuse and provider preferences for mitigating overuse. METHODS Our survey used the Action, Actor, Context, Target, Time (AACTT) framework, the Theoretical Domains Framework (TDF), the Capability, Opportunity, Motivation-Behavior (COM-B) Model, and a DCE to elicit provider de-implementation strategy preferences. We surveyed the Society of Government Service Urologists listserv in December 2020. We stratified respondents based on the likelihood of stopping overuse as ADT monotherapy for localized prostate cancer ("yes"/"probably yes," "probably no"/"no"), and characterized corresponding Likert scale responses to seven COM-B statements. We used multivariable regression to identify associations between stopping ADT overuse and COM-B responses. RESULTS Our survey was completed by 84 respondents (13% response rate), with 27% indicating "probably no"/"no" to stopping ADT overuse. We found differences across respondents who said they would and would not stop ADT overuse in demographics and COM-B statements. Our model identified 2 COM-B domains (Opportunity-Social, Motivation-Reflective) significantly associated with a lower likelihood of stopping ADT overuse. Our DCE demonstrated in-person communication, multidisciplinary review, and medical record documentation may be effective in reducing ADT overuse. CONCLUSIONS Our study used a behavioral theory-informed survey, including a DCE, to identify behaviors and context underpinning ADT overuse. Specifying behaviors supporting and gathering provider preferences in addressing ADT overuse requires a stepwise, stakeholder-engaged approach to support evidence-based cancer care. From this work, we are pursuing targeted improvement strategies. TRIAL REGISTRATION ClinicalTrials.gov, NCT03579680.
Collapse
Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA.
- Department of Surgery, Urology Section, University of Chicago, Chicago, USA.
| | - Sarah T Hawley
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Anne E Sales
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Columbia, MO, USA
| | - Jordan B Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jennifer Burns
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Megan V Caram
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Archana Radhakrishnan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lesly A Dossett
- Department of Surgery, Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Danil V Makarov
- VA New York Harbor Healthcare System and NYU School of Medicine Departments of Urology and Population Health, New York, NY, USA
| | - John T Leppert
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Urology, Stanford University, Stanford, CA, USA
| | - Jeremy B Shelton
- VA Salt Lake City Healthcare System, Salt Lake City, UT, USA
- Department of Urology, University of California, Los Angeles, USA
| | - Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer Dunsmore
- Academic Urology Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | - Steven Maclennan
- Academic Urology Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | - Sameer Saini
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | - Vahakn Shahinian
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniela A Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Varad Deolankar
- Ross School of Business, University of Michigan, Ann Arbor, MI, USA
| | - S Sriram
- Ross School of Business, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
2
|
Skolarus TA, Forman J, Sparks JB, Metreger T, Hawley ST, Caram MV, Dossett L, Paniagua-Cruz A, Makarov DV, Leppert JT, Shelton JB, Stensland KD, Hollenbeck BK, Shahinian V, Sales AE, Wittmann DA. Correction: Learning from the "tail end" of de-implementation: the case of chemical castration for localized prostate cancer. Implement Sci Commun 2023; 4:31. [PMID: 36941664 PMCID: PMC10026413 DOI: 10.1186/s43058-023-00411-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jordan B Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Megan V Caram
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lesly Dossett
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, MI, USA
| | - Alan Paniagua-Cruz
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Danil V Makarov
- VA New York Harbor Healthcare System and NYU School of Medicine Departments of Urology and Population Health, New York, NY, USA
| | - John T Leppert
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Urology, Stanford University, Stanford, CA, USA
| | | | - Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Vahakn Shahinian
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniela A Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| |
Collapse
|
3
|
Hawley ST, Metreger T, Kim H, Skolarus TA. 12-month secondary outcomes of a prostate cancer survivor symptom self-management intervention. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
373 Background: Long term adverse symptoms following treatment for prostate cancer are prevalent and can negatively impact quality of life and increase healthcare seeking, even though many symptoms can be effectively self-managed. There remains a need for tools to support long term survivors to feel confident in their ability to self-manage their symptoms, potentially translating to more efficient health care utilization. Methods: We conducted a RCT of an automated tailored self-management support intervention (vs. newsletter) for long term (> 1 year) Veteran survivors of prostate cancer recruited from 4/2015-2/2017 across four VA sites. Participants were randomized (278 per arm) and assessed via survey at 5 months and 12 months post enrollment. The intervention delivered tailored information regarding symptoms for urinary, sexual, bowel and general health over 3 months, allowing participants to choose focus areas. At 12 months, we assessed secondary trial outcomes; participants’ reports of use of services relative to their symptoms (urinary, bowel, sexual, general health) and their confidence in symptom self-management (scale from 5-15). We also assessed use of procedures and medications related to each symptom area via medical charts. We tested differences in reported and documented service use between arms using T-tests and Chi-square tests. We further assessed participants engagement in components of the intervention. Results: Of those randomized, 81.7% completed the 12-month survey assessment (N = 226 Intervention and N = 228 Control). The average age was 66.7, 28% were Black, and 49% were high school graduates or less. Participants in the intervention arm reported greater confidence in symptom self-management than controls (Mean: 13.5 vs. 12.9; P = 0.01). Intervention participants reported less often using services related to urinary (43.9% vs. 56.0%, P = 0.03) and sexual (42.3% vs. 57.6%, P = 0.04) health over the prior 7 months. Review of intervention paradata found that urinary and sexual health were the topics most frequently engaged with among intervention subjects. No significant differences in medical chart documented procedures related to symptom areas were found. Conclusions: This secondary trial analysis found that 12 months post enrollment, Veterans who engaged with a tailored self-management intervention were more confident in their ability to self-manage their symptoms. The associated finding of fewer visits for the most commonly chosen areas for symptom self-management suggests that such an intervention may hold promise for helping long term survivors to effectively self-manage adverse symptoms. Clinical trial information: NCT01900561.
Collapse
Affiliation(s)
- Sarah T. Hawley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | | | | |
Collapse
|
4
|
Skolarus TA, Forman J, Sparks JB, Metreger T, Hawley ST, Caram MV, Dossett LA, Larkin A, Paniagua Cruz A, Makarov DV, Leppert JT, Shelton JB, Stensland KD, Hollenbeck BK, Shahinian V, Wittmann DA, Deolankar V, Sriram S. Unpacking low-value castration practices using behavior specification to guide de-implementation in prostate cancer care. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e17055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e17055 Background: Many men with prostate cancer will be exposed to ADT at some point during cancer survivorship. Unfortunately, ADT overuse in low-value scenarios is not uncommon (e.g., monotherapy in localized prostate cancer, biochemically-recurrent non-metastatic disease) resulting in more harms than benefits. We conducted an innovative survey study to unpack ADT overuse to inform behavior change and de-implementation strategies. Methods: Our survey used the Theoretical Domains Framework (TDF), and the Capability, Opportunity, Motivation – Behavior (COM-B) Model. The survey was fielded to the Society of Government Service Urologists listserv in December 2020. We stratified respondents based on their likelihood of stopping ADT monotherapy in the case of a localized prostate cancer patient presenting to their office (yes/probably yes, probably no/no), and characterized Likert scale responses to 7 COM-B statements. We used multivariable logistic regression to identify associations between stopping ADT and COM-B responses across a dichotomized Likert scale of “strongly disagree/disagree/neutral” and “agree/strongly agree.”. Results: Our survey was completed by 84 respondents (13% response rate), with 27% indicating ‘probably no’/‘no’ to stopping low-value ADT monotherapy in the case of a localized prostate cancer patient presenting to their office. Our multivariable model identified 2 COM-B statements significantly associated with lower likelihood of stopping low-value ADT. Conclusions: Using an innovative, behavioral theory-informed survey, we identified that providers less likely to stop low-value ADT had greater concern about patient worry and were more interested in providing ADT recommendations consistent with peers, informing de-implementation strategy selection. Clinical trial information: MCT03579680. [Table: see text]
Collapse
Affiliation(s)
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jordan B. Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Sarah T. Hawley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Megan Veresh Caram
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI
| | | | - Angela Larkin
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - Danil V. Makarov
- VA New York Harbor Healthcare System and NYU School of Medicine Departments of Urology and Population Health, New York, NY
| | - John T. Leppert
- Surgical Service, Veteran’s Affairs Palo Alto Health Care System, Palo Alto, CA
| | | | - Kristian D. Stensland
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Brent K. Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Vahakn Shahinian
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Daniela A. Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI
| | - Varad Deolankar
- University of Michigan Ross School of Business, Ann Arbor, MI
| | - S. Sriram
- University of Michigan Ross School of Business, Ann Arbor, MI
| |
Collapse
|
5
|
Skolarus TA, Forman J, Sparks JB, Metreger T, Hawley ST, Caram MV, Dossett L, Paniagua-Cruz A, Makarov DV, Leppert JT, Shelton JB, Stensland KD, Hollenbeck BK, Shahinian V, Sales AE, Wittmann DA. Learning from the "tail end" of de-implementation: the case of chemical castration for localized prostate cancer. Implement Sci Commun 2021; 2:124. [PMID: 34711274 PMCID: PMC8555144 DOI: 10.1186/s43058-021-00224-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 09/30/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Men with prostate cancer are often treated with the suppression of testosterone through long-acting injectable drugs termed chemical castration or androgen deprivation therapy (ADT). In most cases, ADT is not an appropriate treatment for localized prostate cancer, indicating low-value care. Guided by the Theoretical Domains Framework (TDF) and the Behavior Change Wheel's Capability, Opportunity, Motivation Model (COM-B), we conducted a qualitative study to identify behavioral determinants of low-value ADT use to manage localized prostate cancer, and theory-based opportunities for de-implementation strategy development. METHODS We used national cancer registry and administrative data from 2016 to 2017 to examine the variation in low-value ADT use across Veterans Health Administration facilities. Using purposive sampling, we selected high- and low-performing sites to conduct 20 urology provider interviews regarding low-value ADT. We coded transcripts into TDF domains and mapped content to the COM-B model to generate a conceptual framework for addressing low-value ADT practices. RESULTS Our interview findings reflected provider perspectives on prescribing ADT as low-value localized prostate cancer treatment, including barriers and facilitators to de-implementing low-value ADT. We characterized providers as belonging in 1 of 3 categories with respect to low-value ADT use: 1) never prescribe 2); willing, under some circumstances, to prescribe: and 3) prescribe as an acceptable treatment option. Provider capability to prescribe low-value ADT depended on their knowledge of localized prostate cancer treatment options (knowledge) coupled with interpersonal skills to engage patients in educational discussion (skills). Provider opportunity to prescribe low-value ADT centered on the environmental resources to inform ADT decisions (e.g., multi-disciplinary review), perceived guideline availability, and social roles and influences regarding ADT practices, such as prior training. Provider motivation involved goals of ADT use, including patient preferences, beliefs in capabilities/professional confidence, and beliefs about the consequences of prescribing or not prescribing ADT. CONCLUSIONS Use of the TDF domains and the COM-B model enabled us to conceptualize provider behavior with respect to low-value ADT use and clarify possible areas for intervention to effect de-implementation of low-value ADT prescribing in localized prostate cancer. TRIAL REGISTRATION ClinicalTrials.gov , NCT03579680.
Collapse
Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jordan B Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Megan V Caram
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lesly Dossett
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, MI, USA
| | - Alan Paniagua-Cruz
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Danil V Makarov
- VA New York Harbor Healthcare System and NYU School of Medicine Departments of Urology and Population Health, New York, NY, USA
| | - John T Leppert
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Urology, Stanford University, Stanford, CA, USA
| | | | - Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Vahakn Shahinian
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniela A Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| |
Collapse
|
6
|
Skolarus TA, Metreger T, Wittmann D, Hwang S, Kim HM, Grubb RL, Gingrich JR, Zhu H, Piette JD, Hawley ST. Self-Management in Long-Term Prostate Cancer Survivors: A Randomized, Controlled Trial. J Clin Oncol 2019; 37:1326-1335. [PMID: 30925126 DOI: 10.1200/jco.18.01770] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE This randomized clinical trial compared a personally tailored, automated telephone symptom management intervention to improve self-management among long-term survivors of prostate cancer with usual care enhanced with a nontailored newsletter about symptom management. We hypothesized that intervention-group participants would have more confident symptom self-management and reduced symptom burden. METHODS A total of 556 prostate cancer survivors who, more than 1 year after treatment, were experiencing symptom burden were recruited from April 2015 to February 2017 across four Veterans Affairs sites. Participants were randomly assigned to intervention (n = 278) or usual care (n = 278) groups. We compared differences in the primary (symptom burden according to Expanded Prostate Cancer Index Composite-26 [EPIC], confidence in self-management) and secondary outcomes between groups using intent-to-treat analyses. We compared domain-specific changes in symptom burden from baseline to 5 and 12 months among the intervention group according to the primary symptom focus area (urinary, bowel, sexual, general) of participants. RESULTS Most of the prostate cancer survivors in this study were married (54.3%), were white (69.2%), were retired (62.4%), and underwent radiation therapy (56.7% v 46.2% who underwent surgery), and the mean age was 67 years. There were no baseline differences in urinary, bowel, sexual, or hormonal domain EPIC scores across groups. We observed higher EPIC scores in the intervention arm in all domain areas at 5 months, though differences were not statistically significant. No differences were found in secondary outcomes; however, coping appraisal was higher (2.8 v 2.6; P = .02) in intervention-arm patients at 5 months. In subgroup analyses, intervention participants reported improvement from baseline at 5 and 12 months in their symptom focus area domains. CONCLUSION This intervention was well received among veterans who were long-term survivors of prostate cancer. Although overall outcome differences were not observed across groups, the intervention tailored to symptom area of choice may hold promise to improve associated burden.
Collapse
Affiliation(s)
- Ted A Skolarus
- 1 Veterans Affairs Health Services Research and Development Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI.,2 University of Michigan, Ann Arbor, MI
| | - Tabitha Metreger
- 1 Veterans Affairs Health Services Research and Development Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - Soohyun Hwang
- 3 University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC
| | - Hyungjin Myra Kim
- 1 Veterans Affairs Health Services Research and Development Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI.,2 University of Michigan, Ann Arbor, MI
| | - Robert L Grubb
- 4 Medical University of South Carolina, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC
| | - Jeffrey R Gingrich
- 5 Duke University, Durham Veterans Affairs Healthcare System, Durham, NC
| | - Hui Zhu
- 6 Case Western Reserve University, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - John D Piette
- 1 Veterans Affairs Health Services Research and Development Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI.,7 University of Michigan School of Public Health, Ann Arbor, MI
| | - Sarah T Hawley
- 1 Veterans Affairs Health Services Research and Development Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI.,2 University of Michigan, Ann Arbor, MI
| |
Collapse
|
7
|
Skolarus TA, Hawley ST, Wittmann DA, Forman J, Metreger T, Sparks JB, Zhu K, Caram MEV, Hollenbeck BK, Makarov DV, Leppert JT, Shelton JB, Shahinian V, Srinivasaraghavan S, Sales AE. De-implementation of low value castration for men with prostate cancer: protocol for a theory-based, mixed methods approach to minimizing low value androgen deprivation therapy (DeADT). Implement Sci 2018; 13:144. [PMID: 30486836 PMCID: PMC6262964 DOI: 10.1186/s13012-018-0833-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/30/2018] [Indexed: 01/27/2023] Open
Abstract
Background Men with prostate cancer are often castrated with long-acting injectable drugs termed androgen deprivation therapy (ADT). Although many benefit, ADT is also used in patients with little or nothing to gain. The best ways to stop this practice are unknown, and range from blunt pharmacy restrictions to informed decision-making. This study will refine and pilot two different de-implementation strategies for reducing ADT use among those unlikely to benefit in preparation for a comparative effectiveness trial. Methods/design This innovative mixed methods research program has three aims. Aim 1: To assess preferences and barriers for de-implementation of chemical castration in prostate cancer. Guided by the theoretical domains framework (TDF), urologists and patients from facilities with the highest and lowest castration rates across the VA will be interviewed to identify key preferences and de-implementation barriers for reducing castration as prostate cancer treatment. This qualitative work will inform Aim 2 while gathering rich information for two proposed pilot intervention strategies. Aim 2: To use a discrete choice experiment (DCE), a novel barrier prioritization approach, for de-implementation strategy tailoring. The investigators will conduct national surveys of urologists to prioritize key barriers identified in Aim 1 for stopping incident castration as localized prostate cancer treatment using a DCE experiment design. These quantitative results will identify the most important barriers to be addressed through tailoring of two pilot de-implementation strategies in preparation for Aim 3 piloting. Aim 3: To pilot two tailored de-implementation strategies to reduce castration as localized prostate cancer treatment. Building on findings from Aims 1 and 2, two de-implementation strategies will be piloted. One strategy will focus on formulary restriction at the organizational level and the other on physician/patient informed decision-making at different facilities. Outcomes will include acceptability, feasibility, and scalability in preparation for an effectiveness trial comparing these two widely varying de-implementation strategies. Discussion Our innovative approach to de-implementation strategy development is directly aligned with state-of-the-art complex implementation intervention development and implementation science. This work will broadly advance de-implementation science for low value cancer care, and foster participation in our de-implementation evaluation trial by addressing barriers, facilitators, and concerns through pilot tailoring. Trial registration ClinicalTrials.gov Identifier: NCT03579680, First Posted July 6, 2018.
Collapse
Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA. .,Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - Sarah T Hawley
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Daniela A Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Jordan B Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Kevin Zhu
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Megan E V Caram
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Danil V Makarov
- Departments of Urology and Population Health, NYU Langone Medical Center, New York City, NY, USA.,VA New York Harbor Healthcare System, 423 E. 23rd St, New York City, NY, 10010, USA
| | - John T Leppert
- Department of Urology, Stanford University School of Medicine, Grant Building, S-287, 300 Pasteur Drive, Stanford, CA, 94305, USA.,VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Jeremy B Shelton
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA
| | - Vahakn Shahinian
- Division of Nephrology, University of Michigan Medical School, Medical School, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
| | | | - Anne E Sales
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| |
Collapse
|
8
|
Skolarus TA, Metreger T, Kim H, Grubb RL, Gingrich JR, Zhu H, Hwang S, Piette JD, Hawley ST. Self-management in prostate cancer survivors: A randomized controlled trial. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.5011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ted A. Skolarus
- Department of Urology, Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI
| | | | | | | | - Jeffrey R. Gingrich
- University of Pittsburgh Dept of Urol, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Hui Zhu
- Louis Stokes Cleveland VA Medical Center, Case Western Reserve University, Cleveland, OH
| | | | | | - Sarah T. Hawley
- Cancer Surveillance and Outcomes Research Team, University of Michigan, Ann Arbor, MI
| |
Collapse
|
9
|
Skolarus TA, Metreger T, Hwang S, Kim HM, Grubb RL, Gingrich JR, Hawley ST. Optimizing veteran-centered prostate cancer survivorship care: study protocol for a randomized controlled trial. Trials 2017; 18:181. [PMID: 28420419 PMCID: PMC5395886 DOI: 10.1186/s13063-017-1925-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/30/2017] [Indexed: 11/17/2022] Open
Abstract
Background Although prostate cancer is the most common cancer among veterans receiving care in the Veterans Health Administration (VA), more needs to be done to understand and improve survivorship care for this large population. This study, funded by VA Health Services Research & Development (HSR&D), seeks to address the need to improve patient-centered survivorship care for veterans with prostate cancer. Methods/Design This is a two-armed randomized controlled trial (RCT) with a target enrollment of up to 325 prostate cancer survivors per study arm (total anticipated n = 600). Patients will be recruited from four VA sites. Patient eligibility criteria include age range of 40–80 years, one to ten years post-treatment, and currently experiencing prostate cancer symptom burden. We will compare the “Building Your New Normal” program, a personally-tailored automated telephone symptom management intervention for improving symptom self-management to usual care enhanced with a non-tailored newsletter about symptom management. Primary outcomes include changes in symptom burden, bother, and health services utilization at five and 12 months after enrollment. Secondary outcomes include long-term psychosocial outcomes (e.g. subjective health, perceived cancer control). We will use multivariable regression analysis to evaluate the impact of the intervention on primary and secondary outcomes. We will conduct a process evaluation to understand the effective intervention components and explore possibilities for broader implementation and dissemination. Discussion Our central hypothesis is that intervention group participants will have improved and more confident symptom self-management and prostate cancer quality of life following the intervention and that these outcomes will translate to more efficient use of health services. The study results will provide much needed information about how to optimize the quality of care, and life, of veteran prostate cancer survivors. Trial registration ClinicalTrials.gov ID NCT01900561; Registered on 22 July 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1925-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Urology, Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Soohyun Hwang
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Hyungjin Myra Kim
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,University of Michigan Center for Consulting for Statistics, Computing and Analytics Research, Ann Arbor, MI, USA
| | - Robert L Grubb
- Department of Surgery (Urology), St. Louis VA Medical Center, Washington University School of Medicine, 915 North Grand Blvd., St. Louis, MO, 63106, USA
| | - Jeffrey R Gingrich
- Department of Urology, VA Pittsburgh Healthcare System, University of Pittsburgh, 7180 Highland Drive, Pittsburgh, PA, 15206, USA
| | - Sarah T Hawley
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA. .,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
10
|
Valenstein M, Kavanagh J, Lee T, Reilly P, Dalack GW, Grabowski J, Smelson D, Ronis DL, Ganoczy D, Woltmann E, Metreger T, Wolschon P, Jensen A, Poddig B, Blow FC. Using a pharmacy-based intervention to improve antipsychotic adherence among patients with serious mental illness. Schizophr Bull 2011; 37:727-36. [PMID: 19933540 PMCID: PMC3122282 DOI: 10.1093/schbul/sbp121] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Similar to patients with other chronic disorders, patients with serious mental illness (SMI) are often poorly adherent with prescribed medications. OBJECTIVE We conducted a randomized controlled trial examining the effectiveness of a pharmacy-based intervention (Meds-Help) in increasing antipsychotic medication adherence among Department of Veterans Affairs (VA) patients with SMI. We also examined the impact of Meds-Help on psychiatric symptoms, quality of life, and satisfaction with care. METHODS We enrolled 118 patients from 4 VA facilities with schizophrenia, schizoaffective, or bipolar disorder who were on long-term antipsychotics but had antipsychotic medication possession ratios (MPRs) <0.8 in the prior year. Patients were randomized to usual care (UC; n = 60) or the pharmacy-based intervention (Meds-Help; n = 58). We reassessed adherence at 6 and 12 months, at which time patients completed Positive and Negative Symptom Scales (PANSS), Quality of Well-being Scales (QWB), and Client Satisfaction Questionnaires (CSQ-8). RESULTS Prior to enrollment, Meds-Help and UC patients had mean antipsychotic MPRs of 0.54 and 0.55, respectively. At 6 months, mean MPRs were 0.91 for Meds-Help and 0.64 for UC patients; at 12 months, they were 0.86 for Meds-Help and 0.62 for UC patients. In multivariate analyses adjusting for patient factors, Meds-Help patients had significantly higher MPRs at 6 and 12 months (P < .0001). There were no significant differences between groups in PANSS, QWB, or CSQ-8 scores, but power to detect small effects was limited. CONCLUSIONS Congruent with prior studies of patients with other disorders, a practical pharmacy-based intervention increased antipsychotic adherence among patients with SMI. However, SMI patients may require additional care management components to improve outcomes.
Collapse
Affiliation(s)
- Marcia Valenstein
- Department of Veterans Affairs Serious Mental Illness Treatment, Research, and Evaluation Center, Health Services Research and Development, Ann Arbor, MI 48104, USA.
| | - Janet Kavanagh
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Todd Lee
- Center for the Management of Complex Chronic Care, Hines Veterans Affairs Hospital, Hines, IL,Institute for Healthcare Studies and Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Peter Reilly
- John D. Dingell Medical Center, Department of Veterans Affairs, Detroit, MI
| | | | - John Grabowski
- John D. Dingell Medical Center, Department of Veterans Affairs, Detroit, MI
| | - David Smelson
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA,Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA
| | - David L. Ronis
- Department of Veterans Affairs Serious Mental Illness Treatment, Research, and Evaluation Center, Health Services Research and Development, Ann Arbor, MI 48104,University of Michigan School of Nursing
| | - Dara Ganoczy
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Emily Woltmann
- Department of Veterans Affairs Serious Mental Illness Treatment, Research, and Evaluation Center, Health Services Research and Development, Ann Arbor, MI 48104,Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | | | - Patricia Wolschon
- John D. Dingell Medical Center, Department of Veterans Affairs, Detroit, MI
| | - Agnes Jensen
- Department of Veterans Affairs Serious Mental Illness Treatment, Research, and Evaluation Center, Health Services Research and Development, Ann Arbor, MI 48104
| | - Barbara Poddig
- Center for the Management of Complex Chronic Care, Hines Veterans Affairs Hospital, Hines, IL
| | - Frederic C. Blow
- Department of Veterans Affairs Serious Mental Illness Treatment, Research, and Evaluation Center, Health Services Research and Development, Ann Arbor, MI 48104,Department of Psychiatry, University of Michigan, Ann Arbor, MI
| |
Collapse
|
11
|
Krein SL, Metreger T, Kadri R, Hughes M, Kerr EA, Piette JD, Kim HM, Richardson CR. Veterans walk to beat back pain: study rationale, design and protocol of a randomized trial of a pedometer-based internet mediated intervention for patients with chronic low back pain. BMC Musculoskelet Disord 2010; 11:205. [PMID: 20836856 PMCID: PMC2945952 DOI: 10.1186/1471-2474-11-205] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Accepted: 09/13/2010] [Indexed: 11/22/2022] Open
Abstract
Background Chronic back pain is a significant problem worldwide and may be especially prevalent among patients receiving care in the U.S. Department of Veterans Affairs healthcare system. Back pain affects adults at all ages and is associated with disability, lost workplace productivity, functional limitations and social isolation. Exercise is one of the most effective strategies for managing chronic back pain. Yet, there are few clinical programs that use low cost approaches to help patients with chronic back pain initiate and maintain an exercise program. Methods/Design We describe the design and rationale of a randomized controlled trial to assess the efficacy of a pedometer-based Internet mediated intervention for patients with chronic back pain. The intervention uses an enhanced pedometer, website and e-community to assist these patients with initiating and maintaining a regular walking program with the primary aim of reducing pain-related disability and functional interference. The study specific aims are: 1) To determine whether a pedometer-based Internet-mediated intervention reduces pain-related functional interference among patients with chronic back pain in the short term and over a 12-month timeframe. 2) To assess the effect of the intervention on walking (measured by step counts), quality of life, pain intensity, pain related fear and self-efficacy for exercise. 3) To identify factors associated with a sustained increase in walking over a 12-month timeframe among patients randomized to the intervention. Discussion Exercise is an integral part of managing chronic back pain but to be effective requires that patients actively participate in the management process. This intervention is designed to increase activity levels, improve functional status and make exercise programs more accessible for a broad range of patients with chronic back pain. Trial Registration Number NCT00694018
Collapse
Affiliation(s)
- Sarah L Krein
- VA Ann Arbor Health Services Research and Development Center of Excellence, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Layden BT, Minadeo N, Suhy J, Abukhdeir AM, Metreger T, Foley K, Borge G, Crayton JW, Bryant FB, de Freitas DM. Biochemical and psychiatric predictors of Li(+) response and toxicity in Li(+)-treated bipolar patients. Bipolar Disord 2004; 6:53-61. [PMID: 14996141 DOI: 10.1046/j.1399-5618.2003.00093.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND It has not been determined whether biochemical or psychological variables predict clinical response and toxicity to Li(+) treatment. METHODS From 30 Li(+)-treated bipolar patients, we measured biochemical variables in red blood cells (RBCs) that encompassed the cell membrane abnormality and the Li(+)/Mg(2+) competition mechanism. Psychiatric measures of depression, mania, and side effects of Li(+) toxicity were correlated with these biochemical variables. Physician classification of Li(+) response and toxicity for each patient were used for determining whether significant differences in biochemical variables and psychiatric measures existed between full and partial responders, and as well as toxic and non-toxic Li(+)-treated bipolar patients. RESULTS Serum [Li(+)] ([Li(+)]e), the ratio of intracellular RBC to serum Li(+), [Li(+)]i/[Li(+)]e, and phosphatidylcholine shared moderate proportions of variance (10-15%) with several of the psychiatric measures. Physician assessment of full response was predicted by higher levels of [Li(+)]e and lower scores on the Hamilton Slowing subscale (95.6% accuracy), whereas higher lithium-binding constants and higher Hamilton total scores perfectly predicted physician classification of partial response. Higher scores on Hamilton Slowing subscale and General Side Effects (GSE) scale were strongly predictive of physician classified Li(+) toxicity (80% accuracy), whereas lower levels of [Li(+)]e and lower scores on the Hamilton Symptom Severity subscale perfectly predicted physician rated non-toxicity in these patients. CONCLUSIONS We found distinct [Li(+)]e levels that predict response and/or toxicity. Specifically, when [Li(+)]e was in the range of 0.93-1.42 mM, full response without toxicity was predicted; higher values predicted toxicity; lower values predicted partial response.
Collapse
Affiliation(s)
- Brian T Layden
- Departments of Chemistry, Loyola University Chicago, Chicago, IL 60626, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Williams N, Layden BT, Suhy J, Metreger T, Foley K, Abukhdeir AM, Borge G, Crayton J, Bryant FB, Mota de Freitas D. Testing competing path models linking the biochemical variables in red blood cells from Li+-treated bipolar patients. Bipolar Disord 2003; 5:320-9. [PMID: 14525552 DOI: 10.1034/j.1399-5618.2003.00054.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Red blood cells (RBCs) from Li+-treated bipolar patients have shown abnormalities in intracellular Li+ concentration ([Li+]i), Na+/Li+ exchange rates, and membrane phospholipid levels. Based on Li+-loaded RBC studies, we hypothesized that Li+-treated bipolar patients also have varied intracellular free Mg2+ concentrations ([Mg2+]f) as compared with normotensive patients. We addressed how these experimentally determined values are intercorrelated. Assuming that Li+ treatment alters these biochemical parameters, we provide hypothetical pathways based upon structural equation modeling statistics. METHODS In RBCs from 30 Li+-treated bipolar patients, we determined [Li+]i, serum [Li+] ([Li+]e), Na+/Li+ exchange parameters, membrane phospholipid levels, [Mg2+]f, and Li+ membrane binding affinities. Comprehensive statistical analyses assessed correlations among the biochemical data. We used path analysis statistics to propose potential pathways in which the data were correlated. RESULTS We found significant correlations within the three Na+/Li+ exchange parameters and percentage composition of the membrane phospholipids. Additional correlations existed between [Mg2+]f and Vstd, Km, or phospholipid composition, between [Li+]i and percentage of phosphatidylcholine, and between percentage of phosphatidylserine and Km. Based on these findings, we hypothesized and statistically determined the most probable pathway through which these parameters were intercorrelated. CONCLUSIONS Significant correlations existed between the biochemical parameters that describe the cell membrane abnormality and the Li+/Mg2+ competition hypotheses. Using path analysis statistics, we identified a biochemical pathway by which Li+ may assert its cellular effects. This study serves as an illustrative example how path analysis is a valuable tool in determining the direction of a certain biochemical pathway.
Collapse
Affiliation(s)
- Nicole Williams
- Department of Chemistry, Loyola University Chicago, Chicago, IL 60626, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|